Dashboard

Origination

Clario - AI Agent for Medical Coding v1.1

Below is the reformatted clinical note based strictly on the provided information:

Patient Information
- Name: Alicia Blanks  
- Age: 26 years old  
- Gender: Female  
- Date of Service: 11/5/2024  
- Provider: Michael McDowell (Specialty Code: 394800008)  
- Place of Service: Office (11)  
- Visit Type: Established Patient  
- Telehealth: No

Chief Complaint
Patient presents for evaluation of attention/concentration difficulties and is requesting neuropsychological testing and genetic testing.

History of Present Illness (HPI)
- Narrative:  
  The patient reports longstanding symptoms consistent with attention-deficit/hyperactivity disorder (ADHD) that have worsened amid significant occupational stress. She describes herself as a "squirrel type person" with chronic distractibility dating back to childhood. Previously, she managed symptoms with physical activity; however, current knee problems limit this coping strategy. The recent exacerbation of symptoms is attributed to increased responsibilities in a supervisory management position and ongoing harassment from a problematic employee. The harassment includes persistent defamation and multiple complaints to agencies such as the Department of Labor and the Department of Justice, resulting in heightened stress and feelings of being "broken."

- Additional Details:  
  - Onset/Duration: Symptoms have been longstanding since childhood but notably worsened over the past year with her new supervisory role.  
  - Aggravating Factors:  
    - Occupational stress, including persistent harassment at work  
    - Inability to utilize previous coping mechanisms due to physical limitations  
  - Symptom Description:  
    - Difficulty with attention span and organization  
    - Easily distracted, extreme agitation, and feeling scattered  
    - Requires lists and calendar systems to maintain organization  
    - Significant emotional impact with feelings of hatred toward the problematic employee  
  - Associated Features:  
    - Sleep disturbances (waking every hour through the night)  
    - Decreased appetite  
    - Difficulty with cortisol regulation affecting weight management  
    - Hypervigilance and difficulty relaxing

Past Medical History (PMH)
- Psychiatric History:  
  - No prior psychiatric treatment or medication.  
  - No previous ADHD diagnosis or formal evaluation despite longstanding symptoms.  
  - Family history indicated resistance to any mental health medications during childhood.

- Social History:  
  - Background in psychology with law school attendance in Michigan.  
  - Currently employed as a government employee in a supervisory/management role with remote work status.  
  - Resides in the Yorkville area and is a mother to a daughter.

Review of Systems (ROS)
- Sleep: Waking every hour through the night  
- Appetite: Decreased (not really hungry)  
- Psychiatric:  
  - Difficulty with attention/concentration  
  - Increased hypervigilance  
  - Irritability  
  - Difficulty relaxing

Physical Examination
(Note: Formal vital signs were not documented.)

- Mental Status Examination:  
  - Appearance: Not formally documented  
  - Behavior: Talkative and engaged; noted surprise at amount of talking  
  - Speech: Rapid, sometimes tangential, and with a pressured quality  
  - Mood: Stressed and agitated per patient report  
  - Affect: Appropriate to content, animated  
  - Thought Process: Goal-directed with occasional tangentiality; no loosening of associations  
  - Thought Content: Preoccupied with occupational stressor; no suicidal or homicidal ideation documented  
  - Cognition: Alert and oriented  
  - Insight/Judgment: Good insight into symptoms and situation

- ADHD Screening Assessment:  
  The provider administered an ADHD screening questionnaire with the following findings:

Inattention Symptoms:  
  - Difficulty wrapping up final details of tasks  
  - Problems getting organized (relies on lists/calendar systems)  
  - Forgetfulness regarding appointments or obligations  
  - Procrastination on tasks requiring intense thought  
  - Careless mistakes on boring or challenging projects  
  - Difficulty sustaining attention on repetitive work  
  - Occasional problems concentrating on conversation  
  - Tendency to misplace or have difficulty finding things  
  - Easily distracted by environmental activity or noise

Hyperactivity/Impulsivity Symptoms:  
  - Fidgeting and squirming  
  - Feeling overly active with a constant need to move (uses exercise equipment during work)  
  - Leaving her seat in meetings when expected to remain seated  
  - Difficulty unwinding during free time

Screening Conclusion:  
  The preliminary screening tool indicated symptoms consistent with adult ADHD, with a notably high score.

Assessment / Diagnosis
1. Attention-Deficit/Hyperactivity Disorder (ADHD), Combined Presentation:  
   - Clinical reasoning based on longstanding history of inattention, distractibility, hyperactivity, and organizational difficulties, now exacerbated by occupational stress.
  
2. Occupational Stress/Adjustment Disorder:  
   - Significant workplace harassment leading to sleep disturbance, decreased appetite, hypervigilance, and difficulty relaxing. The patient reports feelings of being overwhelmed without organizational support.
  
3. Sleep Disturbance:  
   - Likely secondary to anxiety/stress related to the chronic and exacerbated occupational challenges.

Differential Considerations:  
The provider discussed that the symptoms might also be influenced by severe anxiety triggering brain fog. If anxiety is the primary driver, stimulant medications could potentially worsen her anxiety.

Plan / Treatment

1. Pharmacogenomic Testing:  
   - Buccal swab collected today for pharmacogenomic testing to aid in medication guidance.  
   - Results expected within approximately one week.  
   - Patient provided information regarding accessing the results online.

2. Medication Trial:  
   - Initiated trial of Concerta (methylphenidate extended-release) 27 mg.  
   - Rationale: 27 mg chosen as an appropriate starting dose for adults instead of the typical 18 mg dose.  
   - Extended-release formulation selected to minimize midday dosing and to provide a steady effect over 8-10 hours.  
   - Prescription sent to Costco Naperville Route 59 pharmacy.

3. Patient Education – Medication:  
   - Reviewed potential side effects: heavy caffeination initially, headache, dizziness, racing heart (with rapid acclimation), dry mouth, decreased appetite (especially at lunch), possible end-of-day crash, and rarely diarrhea.  
   - Counselled on the importance of hydration due to increased dehydration risk.  
   - Advised to contact the office if the pharmacy does not have the medication due to a national stimulant shortage, as controlled substances cannot be transferred.

4. Counseling:  
   - Patient is actively seeing a counselor; workplace issues were extensively discussed during the session.

5. Follow-up:  
   - Scheduled return appointment on November 19, 2024, at 2:30 PM (approximately two weeks).  
   - Follow-up will include a review of pharmacogenomic testing results and assessment of the patient’s response to the Concerta trial.  
   - Patient instructed to call the office with any concerns before the next appointment.

Additional Documentation
- Informed Consent: Discussed treatment options and potential side effects; patient consented to pharmacogenomic testing and medication trial.  
- Risk Assessment: Reviewed medication risks and benefits; no current suicidal or homicidal ideation noted.  
- Signature/Date:  
  - Provider: Michael McDowell  
  - Date: 11/5/2024

Quality Grade: High

Additional Questions for Improvement:
1. Would the inclusion of vital signs (if available) be beneficial for future documentation?
2. Is there any additional detail regarding the patient's past medical or family history that could be relevant to treatment decisions?
3. Are there any specific elements of the patient's social support system that should be further explored in subsequent visits?

Formatting

★★★★★5/5

The clinical note is comprehensive and well-structured. It includes all the necessary components such as patient demographics, chief complaint, thorough HPI, past medical history, review of systems, detailed physical exam including mental status evaluation, and a clear assessment/diagnosis with an appropriate plan along with informed consent. This level of detail facilitates accurate coding, billing, and claims processing.

Queries

The provided note does not include any specific details regarding wound treatment such as wound type, measurements, or procedures performed on any wound. Could you please clarify if any wound was treated during this encounter? This is needed to determine if base and add-on CPT codes for wound management should be applied.

Could you provide more detailed family history information related to psychiatric conditions or any other relevant disorders? This data may be beneficial for comprehensive risk assessment and for coding purposes (e.g., ICD-10 code family history elements).

Would it be possible to include formal vital signs in the physical exam section during future visits to further support the evaluation? Including specific measurements like blood pressure, heart rate, and respiratory rate (e.g., CPT codes 99214 often require vital sign documentation for new or established patients).

The clinical note mentions that a pharmacogenomic test was performed via a buccal swab. Could you please clarify which specific gene(s) or panel was ordered? This information is important to accurately select the CPT code (e.g., 81225 for CYP2D6 analysis or another code if a multi‐gene panel was used).

Could you provide a brief description of the patient's 'Appearance' during the mental status examination? This detail is critical for completeness in documentation but was not recorded in the notes.

Can additional information regarding any previous unsuccessful coping strategies or interventions, beyond physical activity, be documented? This may help to better contextualize her current presentation and clarify the decision-making process behind the chosen treatment plan [e.g., ICD-10 codes for occupational stress].

Additionally, please confirm if an Evaluation & Management (E&M) service was provided during this visit. If yes, please provide the details (such as the level of service) so that the appropriate E&M CPT code (for example, 99213 for a moderate complexity office visit) can be included.

Primary Diagnosis

95% Confidence

F90.2 ICD-10-CM i

The patient presents with longstanding inattention, distractibility, and hyperactivity dating back to childhood that have recently worsened. This clinical picture is consistent with Attention-Deficit/Hyperactivity Disorder (ADHD), Combined Presentation. The symptoms reported in the HPI and ADHD screening findings support this diagnosis.

Other Diagnosis

90% Confidence

G47.00 ICD-10-CM i

The report of sleep disturbances, specifically waking every hour during the night, qualifies as a sleep disorder. 'Insomnia, unspecified' (G47.00) is used to describe these symptoms, which appear secondary to her occupational stress and anxiety.

90% Confidence

F43.22 ICD-10-CM i

The patient reports significant occupational stress and harassment resulting in anxiety features, sleep disturbances, decreased appetite, and hypervigilance. These features are consistent with an Adjustment Disorder with Anxiety.

Procedures

85% Confidence

81225 CPT i

A buccal swab was collected for pharmacogenomic testing to guide medication management (Concerta trial). The CPT code 81225 is used for CYP2D6 analysis, pending confirmation that this is the intended test panel.

Performed By Collected by office staff under the direction of Michael McDowell
Modifier Value

Performed On 2024-11-05
Units Or Days 1

Schedule Unknown

Reason Laboratory testing to aid medication management through pharmacogenomics

Payer Rules Evaluation

The only procedure code provided (81225) is mapped to genetic/pharmacogenomic testing, which is not addressed by the payer’s CVI/varicose veins treatment rules. The Payer Rules Description requires procedures for symptomatic lower-extremity chronic venous insufficiency (CVI) only, with specific CPT codes and accompanying clinical, imaging, and conservative therapy documentation. None of the provided diagnosis codes (F90.2, F43.22, G47.00) correlate with lower-extremity CVI, nor do they meet criteria A–D. Additionally, there is no documented evidence of venous reflux, CEAP classification, or documentation of a minimum 3-month duration of symptoms necessary for coverage. Since the requested genetic test is being performed for pharmacogenomic purposes in the treatment of ADHD and related symptoms rather than CVI, this claim for procedure code 81225 does not align with the specified criteria. Needs Clarification on whether this procedure falls under a separate benefit category not addressed by these rules.